Ask for Pectus brace or vacuum bell | د محمد الترشيحي

Pectus Fom

Chest Orthosis Purchase Requisition Form
If you do not know the type of deformity in your rib cage, you can book a video call by clicking on the video calls link with the doctor to help you diagnose and then fill out the medical form below

Choose the Type of Distortion

Chest Protrusion | بروز الصدر

Chest Concavity | تقعر الصدر

First Name

Family Name

E-mail

Date of Birth

Phone Number

Street & House Number

District

Region

City

Postal code

Attach a side picture from the left at an angle of 45

Attach

Attach a side picture from the right at an angle of 45

Attach

Attach a frontal image of the chest from a distance of one meter

Attach

The distance between the anterior axillary lines

The distance between the posterior axillary lines

The distance between the nipples

The distance between the angles of the scapula

Chest circumference at the highest point of the deformity

pectus excavatum width

Pectus Excavatum length

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